Del Re et al. BMC Health Services Research 2013, 13:511 http://www.biomedcentral.com/1472-6963/13/511
RESEARCH ARTICLE
Open Access
MOVE: weight management program across the veterans health administration: patient- and facility-level predictors of utilization Aaron C Del Re1*, Matthew L Maciejewski2,3 and Alex HS Harris3
Abstract Background: Health care systems initiating major behavioral health programs often face challenges with variable implementation and uneven patient engagement. One large health care system, Veterans Health Administration (VHA), recently initiated the MOVE!W Weight Management Program, but it is unclear if veterans most in need of MOVE!W services are accessing them. The purpose of this study was to examine patient and facility factors associated with MOVE!W utilization (defined as 1 or more visits) across all VHA facilities. Methods: Using national administrative data in a retrospective cohort study of eligible overweight (25 < = body mass index (BMI) < 30 and at least one obesity associated comorbidity) and obese (BMI > =30) VHA outpatients, we examined variation in and predictors of MOVE!W utilization in fiscal year (FY) 2010 using generalized linear mixed models. Results: 4.39% (n = 90,230) of all eligible overweight and obese patients using VHA services utilized MOVE!W services at least once in FY 2010. Facility-level MOVE! Utilization rates ranged from 0.05% to 16%. Veterans were more likely to have at least one MOVE!W visit if they had a higher BMI, were female, unmarried, younger, a minority, or had a psychiatric or obesity-related comorbidity. Conclusions: Although substantial variation exists across VHA facilities in MOVE!W utilization rates, Veterans most in need of obesity management services were more likely to access MOVE!W, although at a low level. However, there may still be many Veterans who might benefit but are not accessing these services. More research is needed to examine the barriers and facilitators of MOVE!W utilization, particularly in facilities with unusually high and low reach. Keywords: Obesity, Treatment utilization, MOVE!, Obesity management program, Veterans
Background
MOVE!W weight management program utilization across VA facility
The prevalence of obesity (Body Mass Index (BMI) > 30) has grown steadily over the past several decades to nearly 34% of the United States population in 2008 [1]. Obesity increases risk of developing several chronic health conditions, including cardiovascular disease, diabetes, sleep apnea and other medical conditions [2]. Further, obesity is linked to reduced quality of life, survival [1,3] and increased healthcare costs [4-6]. The prevalence of obesity among the 5.5 million patients treated yearly in the * Correspondence: [email protected] 1 Center of Innovation to Implementation, VA Palo Alto Health Care System & Stanford Medical School, 795 Willow Rd, Menlo Park, CA 94025, USA Full list of author information is available at the end of the article
Veterans Health Administration (VHA) is similar (35%) to that of the general U.S. population [2,3,7]. To address the obesity epidemic in VHA, MOVE!W was developed in 2006 to provide weight loss programs throughout the VHA health system, based on evidence-based principles and to provide a multifaceted approach to treating and managing obesity [8-10]. Veterans are eligible for MOVE!W if they are obese (BMI ≥30) or overweight (25 ≤ BMI 5.5 million) had contact with MOVE!W [12]. It is unclear to what extent
© 2013 Del Re et al.; licensee BioMed Central Ltd. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Del Re et al. BMC Health Services Research 2013, 13:511 http://www.biomedcentral.com/1472-6963/13/511
MOVE!W is reaching veterans with higher BMIs or veterans with obesity-related comorbidities who are at increased risk for adverse events. Previous research has found that utilization of VHA obesity management services in 2002 to 2006 (prior to MOVE!W) was more likely among racial/ethnic minorities, women, younger veterans, and unmarried veterans [11,13]. Veterans with psychiatric conditions were also found to use obesity management services at higher rates if they had obesity-related comorbidities (e.g., diabetes) or filled obesogenic psychiatric medications in VHA [13]. The current analysis extends these prior studies by examining use of MOVE!W services in a national population of veterans in 2010. The purpose of this study was to describe the facility-level variability in the utilization of MOVE!W (defined as 1 or more visits) and to examine patient- and facility-level correlates of MOVE!W use, which can inform MOVE!W-related quality improvement efforts.
Page 2 of 8
Total VHA outpatients in FY2010 (N=5,576,858)
One height and weight value to calculate BMI (N=3,574,765)
Methods Study design and sample
Using the outpatient VHA Decision Support System (DSS) database, we conducted a retrospective cohort study of all veterans from 140 Veterans Affairs Medical Centers (VAMCs) that offered the MOVE!W program in 2010 that had at least one available height and weight to calculate Body Mass Index (BMI). FY2010 was the most recent data available at the time of analysis. There is no reason to believe that this particular year is any different in promotion to clients or providers (or otherwise) than previous or later years. Of the 5,576,858 total VHA outpatients seen in fiscal year (FY) 2010 in these 140 facilities, 64% (N = 3,574,765) had at least one height and weight available to calculate BMI (Figure 1). If there were multiple values per patient available, the median value was used, among biologically plausible (i.e., height < 84 inches and weight < 700 pounds) values, to calculate BMI. Patients were retained in the final sample (N=2,054,367) if they had a BMI > = 30 or 25 < = BMI < 30 and at least one obesity associated comorbidity (e.g., diabetes, hypertension, hyperlipdemia, heart disease, congestive heart failure, cholelithiasis, osteoarthritis, low back pain, gastroesophageal reflux disease, and obstructive sleep apnea). Note that patients >70 years of age are not a targeted group for MOVE!W but we chose to analyze the total population of obese veterans in 2010 to have a more complete understanding of MOVE!W use among all obese veterans and for greater generalizability. Outcome and explanatory variables
The primary outcome of this study was MOVE!W utilization, defined as having at least one MOVE!W outpatient visit in VHA National Patient Care Databases (NPCD) in FY2010 identified using VHA clinic stop codes 372 or 373.VHA stop
Met study inclusion criteria (BMI >= 30 or 25
RESEARCH ARTICLE
Open Access
MOVE: weight management program across the veterans health administration: patient- and facility-level predictors of utilization Aaron C Del Re1*, Matthew L Maciejewski2,3 and Alex HS Harris3
Abstract Background: Health care systems initiating major behavioral health programs often face challenges with variable implementation and uneven patient engagement. One large health care system, Veterans Health Administration (VHA), recently initiated the MOVE!W Weight Management Program, but it is unclear if veterans most in need of MOVE!W services are accessing them. The purpose of this study was to examine patient and facility factors associated with MOVE!W utilization (defined as 1 or more visits) across all VHA facilities. Methods: Using national administrative data in a retrospective cohort study of eligible overweight (25 < = body mass index (BMI) < 30 and at least one obesity associated comorbidity) and obese (BMI > =30) VHA outpatients, we examined variation in and predictors of MOVE!W utilization in fiscal year (FY) 2010 using generalized linear mixed models. Results: 4.39% (n = 90,230) of all eligible overweight and obese patients using VHA services utilized MOVE!W services at least once in FY 2010. Facility-level MOVE! Utilization rates ranged from 0.05% to 16%. Veterans were more likely to have at least one MOVE!W visit if they had a higher BMI, were female, unmarried, younger, a minority, or had a psychiatric or obesity-related comorbidity. Conclusions: Although substantial variation exists across VHA facilities in MOVE!W utilization rates, Veterans most in need of obesity management services were more likely to access MOVE!W, although at a low level. However, there may still be many Veterans who might benefit but are not accessing these services. More research is needed to examine the barriers and facilitators of MOVE!W utilization, particularly in facilities with unusually high and low reach. Keywords: Obesity, Treatment utilization, MOVE!, Obesity management program, Veterans
Background
MOVE!W weight management program utilization across VA facility
The prevalence of obesity (Body Mass Index (BMI) > 30) has grown steadily over the past several decades to nearly 34% of the United States population in 2008 [1]. Obesity increases risk of developing several chronic health conditions, including cardiovascular disease, diabetes, sleep apnea and other medical conditions [2]. Further, obesity is linked to reduced quality of life, survival [1,3] and increased healthcare costs [4-6]. The prevalence of obesity among the 5.5 million patients treated yearly in the * Correspondence: [email protected] 1 Center of Innovation to Implementation, VA Palo Alto Health Care System & Stanford Medical School, 795 Willow Rd, Menlo Park, CA 94025, USA Full list of author information is available at the end of the article
Veterans Health Administration (VHA) is similar (35%) to that of the general U.S. population [2,3,7]. To address the obesity epidemic in VHA, MOVE!W was developed in 2006 to provide weight loss programs throughout the VHA health system, based on evidence-based principles and to provide a multifaceted approach to treating and managing obesity [8-10]. Veterans are eligible for MOVE!W if they are obese (BMI ≥30) or overweight (25 ≤ BMI 5.5 million) had contact with MOVE!W [12]. It is unclear to what extent
© 2013 Del Re et al.; licensee BioMed Central Ltd. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Del Re et al. BMC Health Services Research 2013, 13:511 http://www.biomedcentral.com/1472-6963/13/511
MOVE!W is reaching veterans with higher BMIs or veterans with obesity-related comorbidities who are at increased risk for adverse events. Previous research has found that utilization of VHA obesity management services in 2002 to 2006 (prior to MOVE!W) was more likely among racial/ethnic minorities, women, younger veterans, and unmarried veterans [11,13]. Veterans with psychiatric conditions were also found to use obesity management services at higher rates if they had obesity-related comorbidities (e.g., diabetes) or filled obesogenic psychiatric medications in VHA [13]. The current analysis extends these prior studies by examining use of MOVE!W services in a national population of veterans in 2010. The purpose of this study was to describe the facility-level variability in the utilization of MOVE!W (defined as 1 or more visits) and to examine patient- and facility-level correlates of MOVE!W use, which can inform MOVE!W-related quality improvement efforts.
Page 2 of 8
Total VHA outpatients in FY2010 (N=5,576,858)
One height and weight value to calculate BMI (N=3,574,765)
Methods Study design and sample
Using the outpatient VHA Decision Support System (DSS) database, we conducted a retrospective cohort study of all veterans from 140 Veterans Affairs Medical Centers (VAMCs) that offered the MOVE!W program in 2010 that had at least one available height and weight to calculate Body Mass Index (BMI). FY2010 was the most recent data available at the time of analysis. There is no reason to believe that this particular year is any different in promotion to clients or providers (or otherwise) than previous or later years. Of the 5,576,858 total VHA outpatients seen in fiscal year (FY) 2010 in these 140 facilities, 64% (N = 3,574,765) had at least one height and weight available to calculate BMI (Figure 1). If there were multiple values per patient available, the median value was used, among biologically plausible (i.e., height < 84 inches and weight < 700 pounds) values, to calculate BMI. Patients were retained in the final sample (N=2,054,367) if they had a BMI > = 30 or 25 < = BMI < 30 and at least one obesity associated comorbidity (e.g., diabetes, hypertension, hyperlipdemia, heart disease, congestive heart failure, cholelithiasis, osteoarthritis, low back pain, gastroesophageal reflux disease, and obstructive sleep apnea). Note that patients >70 years of age are not a targeted group for MOVE!W but we chose to analyze the total population of obese veterans in 2010 to have a more complete understanding of MOVE!W use among all obese veterans and for greater generalizability. Outcome and explanatory variables
The primary outcome of this study was MOVE!W utilization, defined as having at least one MOVE!W outpatient visit in VHA National Patient Care Databases (NPCD) in FY2010 identified using VHA clinic stop codes 372 or 373.VHA stop
Met study inclusion criteria (BMI >= 30 or 25
